These days, cheerleaders are a lot like acrobats. And there’s been some debate over whether cheerleading is a sport. Some cheerleading organizations say it does not meet criteria necessary to be considered a sport. But the AAP says it should be treated like one, because like other athletes, cheerleaders can sustain serious injuries.

“Cheerleading has become extremely competitive in the past few years, incorporating more complex skills than ever before,” said pediatric sports medicine specialist Dr. Cynthia LaBella, a member of the AAP Council on Sports Medicine & Fitness and co-author of the new guidelines. “Relatively speaking, the injury rate is low compared to other sports, but despite the overall lower rate, the number of catastrophic injuries continues to climb. That is an area of concern and needs attention for improving safety.”

Most cheerleading injuries involve sprains and strains to the lower extremities, but some can be more life-threatening. According to the report, concussions and other closed-head injuries account for 4 to 6% of all cheerleading injuries. And head and neck trauma make up approximately 15% of all cheerleading injuries seen in U.S. emergency rooms.

That’s because cheerleading requires physically demanding skills, such as pyramid building, flipping, tossing, lifting, kicking and catching people in the air. According to the report, these stunts account for 42 to 60% of all injuries, and 96% of all concussions. The paper also notes that cheerleading is one of the highest-risk sporting events for direct catastrophic injuries that can result in permanent brain injury, paralysis or death, especially at the college level.

“Most serious injuries, including catastrophic ones, occur while performing complex stunts such as pyramids,” according to Dr. Jeffrey Mjaanes, also a member of the AAP Council on Sports Medicine & Fitness and co-author of the new guidelines. “Simple steps to improve safety during these stunts could significantly decrease the injury rate and protect young cheerleaders.”

The AAP says cheerleading should be considered a sport in all states and subject to the same rules and regulations that other sports follow.

They also recommend cheerleaders have physicals before each season to make sure they are strong enough to participate as well as be supervised by qualified coaches who have been trained in proper spotting for gymnastics and other stunts.

The AAP also believes cheerleaders should limit their stunts, as well as avoid hard surfaces when performing them. And like any other athlete, cheerleaders should be checked and monitored for concussions if they have a head injury.

The AAP urges coaches, parents and school officials to follow injury-prevention guidelines, develop emergency plans and ensure cheerleading programs have access to the same level of medical care and injury surveillance as other sports.